Case Study: Repeat Cesarean Section with Twin Delivery

Transcription

1 ICD-10-CM Coding Workbook for OB/GYN Case Study: Repeat Cesarean Section with Twin Delivery Case Study: Repeat Cesarean Section with Twin Delivery Preoperative Diagnosis: 1. A 37-week twin intrauterine pregnancy. 2. Prior cesarean section x1. Postoperative diagnoses: 1. A 37-week twin intrauterine pregnancy. 2. Prior cesarean section x1. Procedure Performed: Repeat low transverse cesarean section through a Pfannenstiel skin incision. Anesthesia: Spinal with Duramorph. Estimated Blood Loss: 800 ml. Complications: None. Drains: Foley catheter. Findings: 1. Twin A 2780 grams female infant with Apgar s of 8 and 9 in the vertex presentation. 2. Twin B 2185 grams female infant with Apgar s of 8 and 9 in the vertex presentation, 3. Normal placenta, uterus, tubes, and ovaries. Indications: The patient is a 29-year-old female G 2 P 1 A 0. Her first pregnancy with spontaneous labor resulted in a cesarean delivery due to decelerations of the infant heart rate. The patient requested a repeat cesarean delivery secondary to prior delivery history and twins. She is 37 weeks, 2 days and has experienced onset of labor pains. Procedure: The patient had initial of spinal anesthesia prior to presentation in the operating suite. Level of spinal anesthesia was verified. She was placed in the dorsal supine position with a left tilt. A Foley catheter was inserted. The patient was then prepped and draped in sterile fashion. A Pfannenstiel skin incision was made through previous incision and it was extended out to the deeper layers with the second scalpel. Hemostasis was achieved using Bovie cauterization. The fascia was incised horizontally from margin to margin. The rectus muscle was bluntly and sharply dissected off the fascia inferiorly and superiorly. The rectus muscle was then bluntly and sharply dissected with access to the peritoneum below and extended vertically avoiding the bladder inferiorly. Retractors were placed and the vesicouterine segment of the peritoneum was incised and the midline extended on either side. This layer was dissected off the lower uterine segment. A low transverse uterine incision was then made with the scalpel. The incision was extended bluntly and membranes of baby A were ruptured with clear fluid. The baby girl was delivered from the vertex presentation without difficulty. Mouth and nose were suctioned and the baby cried spontaneously. The cord was double clamped and cut. The baby was handed off to the nurse after being shown to the parents. The baby was in good condition. Apgars were 8 and 9 and the infant weighed 2780 grams OptumInsight, Inc. 87

2 Case Study: Repeat Cesarean Section with Twin Delivery ICD-10-CM Coding Workbook for OB/GYN The second baby was also in the vertex presentation, the membranes of that sac were ruptured with clear fluid. The baby girl was delivered with fundal pressure without difficulty. The baby was appeared smaller, but did cry spontaneously after the mouth and nose were suctioned of clear fluid. The baby's cord was double clamped and cut. The baby was shown to the parents after crying vigorously. Apgar s were also 8 and 9 and the infant weighed 2185 grams. Cord bloods were obtained from each placenta. The placentas were manually extracted from the uterus teasing the membranes with the Kelly clamp. The inside of the uterus was wiped clean with a dry lap sponge. The uterine incision was closed in two layers, using a running interlocking 0 chromic. Hemostasis was adequate and the vesicouterine segment of the peritoneum was closed with 2-0 Vicryl running sutures. Irrigation was performed at this time to remove all blood and clots. The uterus was placed back into the abdominal cavity and contracted well. The edges of the peritoneum reapproximated and then closed with 0 Vicryl running sutures. A piece of Seprafilm was placed over the lower uterine segment peritoneum. The parietal peritoneum was closed with 0 Vicryl running sutures and the rectus muscle closed with 0 Vicryl interrupted sutures. An On-Q pump with double lumen will be used for postoperative pain management. The first puncture site was used to place one end below the muscle and just above the peritoneum. A second puncture site was used to place an Angiocath below the fascia and just above the muscle. The abdomen was irrigated after the rectus muscle was closed. The fascia was then closed with 0 Vicryl running suture, one from either side, toward the midline. Subcutaneous fat layer was closed with 3-0 Vicryl running suture and the skin was closed with staples. The On-Q lumens were steri-stripped in place. The incisions were cleaned and sterile dressing applied. A small amount of blood was expressed from the uterus. Counts were correct including sponge, lap, and needles x2. The patient was then transferred to the recovery room, and the twin girls were evaluated in the nursery in good condition OptumInsight, Inc.

3 ICD-10-CM Coding Workbook for OB/GYN Case Study: Repeat Cesarean Section with Twin Delivery Questions 1. Select the appropriate codes for this procedure. 2. What code is used to report the need for postoperative pain control? a. A. N94.89 b. G89.18 c. R10.9 d. Pain is not reported at this encounter 3. What additional outcome of delivery information should be reported on the mothers chart when twins are delivered? a. Outcome of delivery was twins b. Outcome of delivery and status of twins c. Only report outcome if one or both are stillborn d. The infant apgar scores 4. What code from category Z38 is reported on the mothers chart? a. Z38.31 b. Z38.5 c. Z38.01 x 2 d. Category Z38 is not reported on the mothers chart 2013 OptumInsight, Inc. 89

4 Case Study: Repeat Cesarean Section with Twin Delivery ICD-10-CM Coding Workbook for OB/GYN Questions and Rationale 1. Select the appropriate codes for this procedure. O75.82 Onset (spontaneous) of labor after 37 completed weeks of gestation but before 39 completed weeks gestation, with delivery by (planned) cesarean section O34.21 Maternal care for scar from previous cesarean delivery O Twin pregnancy, dichorionic/diamniotic, third trimester Z3A weeks gestation of pregnancy Z37.2 Twins, both liveborn The scheduled cesarean delivery was performed on this day due to the start of the labor process. The cesarean was scheduled due to a previous cesarean delivery and the patient s desire with consideration of twins. The planned cesarean section is reported with O The primary term in the index is delivery. The subterm is cesarean (for) and occurring after 37 completed weeks. A note in the tabular listing reminds the coder to report the previous cesarean section with code O This can also be found under the primary term delivery and subterm cesarean (for). The additional subterm is previous and includes cesarean delivery. When there are multiple fetus the coding should also include information regarding the placenta and amniotic sac. In this report there are two separate placentas as two separate amniotic sacs. The code to identify this is in the category O30. The primary index term is pregnancy and subterm twin. Additional subterm identify the chorionic (placenta) and amniotic combination. In this scenario it would be dichorionic and diamniotic as the report specifically identifies two placentas and two amniotic sacs. All maternity charts need to include the weeks of gestation. See the Official Guidelines for ICD-10-CM 1.C.15.b.5. This scenario reports 37 weeks and two days. The code Z3A.37 identifies this. The primary index term is pregnancy and subterm weeks of gestation. The code can then identify the total number of weeks and confirm in the tabular listing. The outcome of delivery is reported with a code from the category Z37. The primary term in the index is outcome of delivery. The subterm is twins, and the additional subterm identifies that the both twins are liveborn. 2. What code is used to report the need for postoperative pain control? a. A. N94.89 b. G89.18 c. R10.9 d. Pain is not reported at this encounter Management of postoperative pain is not separately reported. The Official Guidelines for ICD-10-CM state in 1.C.6.b.1 that A code from category G90 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/management and not management of the underlying condition. Thus, the postoperative pain control is considered part of the management of the initial surgery. 3. What additional outcome of delivery information should be reported on the mothers chart when twins are delivered? a. Outcome of delivery was twins b. Outcome of delivery and status of twins c. Only report outcome if one or both are stillborn d. The infant apgar scores OptumInsight, Inc.

5 ICD-10-CM Coding Workbook for OB/GYN Case Study: Repeat Cesarean Section with Twin Delivery The outcome of delivery with a code from category Z37 is reported on the mothers chart. See the Official Guidelines for ICD-10-CM 1.C.15.b.5. This identifies the number of infants, and the status (liveborn or stillbirth). A note in the tabular listing for category Z37 states, This category is intended for use as an additional code to identify the outcome of delivery on the mother s record. 4. What code from category Z38 is reported on the mothers chart? a. Z38.31 Twin liveborn infant, delivered by cesarean b. Z38.5 Twin liveborn infant, unspecified as to place of birth c. Z38.01 x 2 Single liveborn infant delivered by cesarean d. Category Z38 is not reported on the mothers chart A note in the tabular listing for category Z38 states, This category is for use as the principal code on the initial record of a newborn baby It is not to be used on the mother s record OptumInsight, Inc. 91

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